I’ve been lucky in my career in that I’ve seen so many impossible-sounding goals achieved by inspiring individuals who have taught me a lot about the power of a can-do mentality.
None has done so more than Brian Sharp, a wonderfully charismatic South African who set up a cross-border regional malaria control initiative with Mozambique and Eswatini (formerly Swaziland) and then helped shape the global malaria-control funding landscape that saves about half a million lives a year today.
Sadly, Brian is no longer with us but his words still echo in my head every time I face a problem I know is technically soluble but seems logistically or politically overwhelming: “Don’t talk to me about problems, talk to me about solutions.”
Brian’s leadership qualities and contagious problem-solving attitude could not be more different from the defeatist language I’ve heard from our authorities in relation to missed opportunities to eliminate Covid-19 from the island of Ireland. I don’t accept our flippant dismissal of approaches that have delivered a Covid-free existence for more than a billion people in a diversity of separate countries, each with its own distinctive social, economic, political and geographic circumstances.
Based on my experience of large-scale, population-wide public health programmes under conditions far more difficult than those on our small, quite wealthy island, I just don’t accept that we have to “live with the virus”. Terminological white flags like “impractical”, “unrealistic” or “impossible” are simply not technically valid in relation to a virus that has been eliminated from so many jurisdictions with such low-tech interventions as soap and water, distancing, cloth face coverings, hand hygiene, local travel controls, international travel quarantines, passive surveillance for symptomatic cases, and good old-fashioned outbreak investigation.
All these proven approaches are available to us, and new options such as rapid antigen tests can only help our cause, so here I summarise all the things we can do in Ireland if we can just get past the “can’t do, won’t do” mindset that is holding us back.
We clearly can shrink our epidemic with astutely balanced packages of restrictions –we’ve done so successfully twice now. Encouragingly, observed epidemic contraction rates for both our first and second waves compare well with countries that have eliminated Covid. In fact, our phase-one response to our first wave was every bit as effective as equivalent efforts in China, and our level-5 response to the our second wave looks set to follow suit without compromising any of our cherished democratic norms of participatory population mobilisation.
As in China, Vietnam, Taiwan, South Korea, New Zealand and Australia, if we were to patiently persist with current restrictions, our epidemic would fizzle out by January or February. Of course, sooner is better than later, so what could we do the speed that process up?
We can accelerate our progress towards elimination of Covid by making full use of rapid antigen tests, not as a substitute for the gold-standard PCR test used for routine passive surveillance and outbreak investigation, but rather as a supplementary tool for active surveillance platforms that would not otherwise be feasible. Sure, antigen tests are not as sensitive as the PCR tests, but new active surveillance platforms such as serial testing of essential workers outside of healthcare or residential care settings don’t need to detect each and every infection. They just need to identify a single index case within a transmission chain before it becomes too extended and disseminated to fully trace and contain.
Once flagged up by an index case, the rest of the transmission chain can then be mapped out with more sensitive PCR tests, and even serological tests that can detect antibodies persisting long after the virus has gone, so that each and every infection can be traced to a common ancestor case. Public health teams can then be sure no-one carrying the virus infection slips through the net and keep that viral lineage alive.
Perfect test sensitivity is far less important than simply doing more tests on more people, and testing them more often, to maximise the number of index cases caught during the short period when virus levels are high enough to detect.
By my calculations (plain parlance for modelling!) comprehensive transmission chain containment can be achieved with retrospective tracing at least a week into the past (the current 48-hour window is insufficient) if just one third of all infections can be detected as index cases through routine surveillance. The simple explanation for this threshold is that transmission chains will be picked up frequently enough by routine surveillance to catch them before they become too large and spread out to track comprehensively.
Rapid antigen tests have been good enough for decentralised, community-based deployment against malaria all across Africa, where astute public health professionals know how to deal with their imperfections. Let’s empower our expert public health teams to get on with figuring out for themselves how best to use these new tools.
This brings me to my next subject. We can abandon our adherence to an excessively narrow and dogmatic interpretation of what evidence-based medicine really means. Remember how long it took our authorities to accept the existence of transmission without obvious symptoms, the effectiveness of face coverings and, just recently, the inadequacies of visors? An institutionalised “ivory tower” style of evidence-based medicine has been increasingly challenged by the global public health community over recent years and has now been ruthlessly exposed by Covid as a ponderous behemoth.
One classic piece in the British Medical Journal humorously highlighted the lack of rigorous evidence available to support parachute use and suggested that “everyone might benefit if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled crossover trial”, presumably from the highest altitude possible. Current circumstances dictate that we now embrace more flexible and dynamic decision-making frameworks, giving greater emphasis to the invaluable discipline of operational research.
Operational research was invented in the second world war (to optimise tactics for sinking U-boats, in case you’re curious) and forms the backbone of health services research in the most challenging settings globally. In simple terms, operational research means you just get on with finding ways to solve a problem through new routine practices, and document all your successes and failures as you go along, so that you finish with hard evidence rather than just anecdotes and strong opinions.
Let’s take rapid antigen tests as an example of a technology that can and should be evaluated immediately through operational research outside of our hospitals and laboratories. As a professional, I’ve been responsible for deployment of hundreds of thousands of these miraculous little devices, resulting in tens of thousands of treatments for chronic, debilitating malaria infections which the affected individuals never knew they were carrying around.
In my personal life I’ve relied on these cheap and cheerful tests to protect my family from the worst consequences of malaria and I’m not sure we’d all be here without them. They work fine if you understand their imperfections and use them accordingly. On several occasions I’ve tested our children three days in a row because I couldn't completely trust a single negative result based on what I know about the performance characteristics of the test and the dynamics of malaria parasite infections.
We can trust our public health physicians to figure their way through these issues and have them tell their laboratory and health facility-based colleagues what best practice looks like rather than vice versa.
We can trust our public health specialists and shouldn’t wait another day to give them all proper consultant contracts so they have the authority and freedom to do their jobs. While some journalists and broadcasters have represented their struggles as a petty pay dispute, that’s not their primary issue. Coming from a non-clinical public health background working on whole population interventions, I know how frustrating it can be when you lack the authority to make the decisions that matter in an arena where you are the real expert.
Public health physicians are a breed apart who have a unique understanding of how to engage entire communities and deliver programmes to entire populations beyond the reach of other specialities based in clinics and hospitals. I understand the frustrations of having to convince a conventional facility-based physician to make the right call in a technical discipline that’s outside of their experience and expertise, and then cajole them into giving it policy and budget priority.
We only have 60 or so public health specialists in Ireland and anyone who thinks they are calling the shots in our national response has been misled. They are currently completely submerged in an unmanageable deluge of outbreaks created by high-level decision makers who have refused to provide them with the consultant positions they need to lead our emergency response effort.
Beyond their technical roles at the frontline, we also need them to engage more freely with the public, to help guide us through this crisis. The vacuum left in public discourse by their conspicuous absence has been filled by an odd collection of less qualified folks, including myself, and that needs to end. An Irish public health consultant working on the frontline should be writing this article but you’re stuck with me because I’m available, free to speak publicly and don’t have any competing interests.
We can all empower our critical A-team cadre of disenfranchised public health specialists in two ways. First, we can insist that the demands they’ve made through the Irish Medical Organisation are met without further delay. Second, we can persist with ongoing restrictions until the numbers of ongoing outbreaks in the country reach manageable levels (about five cases per day) so those public health experts can spend less time in the trenches and more time back in HQ where we will need them for the final push towards sustained elimination.
Once we have eliminated local transmission of Covid, we can keep it out. Not easy, especially given the complicated history of the land border that traverses our island, but certainly no more difficult than it was for the various states of China or Australia to get to a Covid-free status and stay there.
Looking at travel controls within and between the Republic and Northern Ireland, we can implement a “border bubble” system like those used by neighbouring Australian states, which allowed residents of communities living close to boundaries to cross them but not go too much further. All that’s required is proof of address, proof of a good reason to cross a boundary regularly (e.g. address for a workplace or relative in need of care) so that a machine-readable pass card can be issued and verified at check points. Ideally, both jurisdictions could agree on a shared administrative system but the Republic could also implement one unilaterally. For example, qualifying, verified residents of Donegal could visit Derry or Leitrim but wouldn’t be able to visit Dublin without specific additional permissions.
We could also make the task easier by breaking the country into more logical, practically manageable travel zones centred around major commuter hubs, rather than relying on historical county boundaries. It would be nice for those of us in the Republic if we could agree on a joint plan with our friends in the North and elsewhere in Europe, but I suspect we would achieve more if we simply led by example with smart, effective local travel controls within our own jurisdiction.
As for international trade and travel, those solutions also exist and can be adapted to our needs. I’ve long advocated for trailer exchange depots at Irish ports and was reassured to hear that similar practices have proven effective for interstate surface freight in Australia. The whole idea is that goods can enter the country but the driver just heads straight home on the next ferry while a resident driver of an Irish-registered truck takes it onward within the country. There’s no reason existing protocols for managing air crews, truck drivers and ferry crews can’t be adapted from Australia or other successful countries.
For air passengers, high frequency serial testing could shorten isolation times, but such protocols would need very careful planning, assessment and monitoring on pilot scales before adoption as the norm. Ultimately, the best way to get around the need for rigorous isolation on arrival is to build up travel bubbles between successful jurisdictions as we all pursue sustainable elimination endpoints. The real solution is not to minimise short-term pain but rather to maximise medium-term gain by reopening international travel across Europe on a Covid-free basis over the months ahead.
All the above can be done in Ireland and is being done successfully in several countries across Asia and the Pacific. Most people on the island are already doing everything within their power as individuals at great personal cost but cannot take on the essential roles of government and centralised authorities. Individuals, families and businesses cannot introduce, implement or enforce the kind of decisive policies required to get us out of this predicament by early spring.
Our governments and authorities now need to make a strategic commitment to pro-actively eliminating Covid from the island. And they need to back that up with a “can do” attitude to finding practical solutions. Unless we’re all ready to accept further cycles of epidemic waves and reactive lockdowns, none of us should accept anything less.
Professor Gerry Killeen is research chair in applied pathogen ecology at University College Cork